Transcript Lecture 9 - Malignant uterine tumor.pptx

ENDOMETRIAL CANCER
KARIMA SALAMA
ENDOMETRIAL CANCER
• Epidemiology
• Most common gynecological cancer in the
developed countries, with an incidence of 12.9
per 100,000 women and a mortality rate of 2.4 per
100,000.
• In developing countries, it is the second most
common gynecologic malignancy, with an
incidence of 5.9 per 100,000 and a mortality rate
of 1.7 per 100,000.
• The average age of diagnosis of uterine cancer in
the US is 61 years old
• From ages 50 to 70, women have a 1.4% risk of
being diagnosed with uterine cancer
• Women in the US have a 2.6% lifetime risk of
developing uterine cancer
HISTOLOGICAL TYPES
• Two histologic categories:
• Type I
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Endometrioid histology.
Grade 1 or 2.
80 percent of endometrial carcinomas.
favorable prognosis, are estrogen-responsive, and may
be preceded by an intraepithelial neoplasm (atypical
and/or complex endometrial hyperplasia).
• Type II tumors
• 10 to 20 percent of endometrial carcinomas.
• Grade 3 endometrioid tumors & serous, clear cell,
mucinous, squamous, transitional cell, mesonephric,
and undifferentiated.H
• igh-grade.
• Poor prognosis, and are not clearly associated with
estrogen stimulation. A precursor lesion is rarely
identified
RISK FACTORS
• Type I … estrogen dependent tumor
• Exogenous estrogen
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Tamoxifen
Unopposed systemic estrogen therapy
Postmenopausal estrogen therapy
Phytoestrogen
• Endogenous estrogen
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Chronic anovulation
Early menarche --- late menopause
Obesity
Estrogen secreting tumors
RISK FACTORS
• Family history and genetics predisposition
• Lynch syndrome (hereditary nonpolyposis colorectal
cancer)
• Autosomal dominant caused by a germline mutation in one of
several DNA mismatch repair genes
• Develop the disease at a young age.
• Accounts for two to five percent of all endometrial carcinomas.
• Women with Lynch syndrome, the lifetime risk of endometrial
carcinoma is 27 to 71 percent compared with 2.6 percent in the
general population
• Mean age of diagnosis of endometrial cancer 46-54yrs
• BRCA I mutation
• BRCA1 mutation carriers reported a significant increase in
the risk of uterine cancer (RR 2.65, 95% CI 1.69-4.16).
• Data from a prospective series suggested that the risk of
endometrial carcinoma was significantly elevated only for
BRCA mutation carriers taking tamoxifen
ASSOCIATED FACTORS
• Nulliparity and infertility
• The risk of endometrial carcinoma is inversely related to
parity.
• Nulliparity and infertility do not appear to independent risk
factors for endometrial carcinoma; instead, the association
is probably with the high frequency of anovulatory cycles in
infertile women.
• Data are inconsistent regarding whether ovulation
induction for treatment of infertility is associated with an
increased risk of endometrial carcinoma.
• Diabetes and hypertension
• Women with diabetes mellitus and hypertension
are at increased risk for endometrial carcinoma.
• Comorbid factors, primarily obesity, account for
much of this risk, but some studies have found
independent effects, as well.
• The risk of developing endometrial carcinoma is
higher in type 2 than type 1 diabetics. Diets high in
carbohydrates and associated hyperinsulinemia,
insulin resistance, and elevated levels of insulin-like
growth factors may play a role in endometrial
proliferation and development of endometrial
carcinoma; this is an area of active investigation
• Breast cancer
• A history of breast cancer is a risk factor for development of
endometrial carcinoma, clearly in women treated with
tamoxifen
PROTECTIVE FACTORS
• Hormonal contraceptives
• The use of estrogen-progestin oral contraceptives (OCs)
decreases the risk of endometrial carcinoma by 50 percent
or higher
• The benefit of hormonal contraceptives is likely due to the
progestin component, which suppresses endometrial
proliferation.
• Studies have found that progestin-only contraceptives
provide endometrial protection against development of
endometrial neoplasia
PROTECTIVE FACTORS
• Increasing age at last birth
• Childbearing at an older age, independent of parity and
other factors, was associated with a decreased risk of
endometrial carcinoma. As an example, women who last
gave birth at age 35 to 39 years had a 32 percent decrease
in risk (95% CI 0.61-0.76).
• Smoking
• Cigarette smoking is associated with a decreased risk of
developing endometrial carcinoma in postmenopausal
women
PROTECTIVE FACTORS
• Physical activity
• Coffee and tea
• Smoking
CLINICAL PRESENTATION
• Abnormal uterine bleeding
• Suspicion of the presence of endometrial neoplasia
(neoplastic endometrial hyperplasia or carcinoma)
depends upon symptoms, age, and the presence of risk
factors.
• Abnormal uterine bleeding is present in approximately 75 to
90 percent of women with endometrial carcinoma
• The amount of bleeding does not correlate with the risk of
cancer.
CLINICAL MANIFESTATION
• Postmenopausal women
• Any bleeding, including spotting or staining. Three to 20 percent of women
with postmenopausal bleeding are found to have endometrial carcinoma
and another 5 to 15 percent have endometrial hyperplasia.
• Age 45 to menopause
• Any abnormal uterine bleeding, Among cases of endometrial carcinoma,
19 percent occur in women aged 45 to 54 years compared with 6 percent
in those aged 35 to 44 years.
• Younger than 45 years
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Abnormal uterine bleeding that is persistent, occurs in the setting of a
history of unopposed estrogen exposure (obesity, chronic anovulation) or
failed medical management of the bleeding, or in women at high risk of
endometrial cancer ( Lynch syndrome)
CLINICAL MANIFESTATION
• Abnormal PAP smear..
• Adenocarcinoma – Adenocarcinoma is sometimes seen on cervical
cytology. Since the malignant cells may arise from either the cervix or
endometrium, further evaluation with cervical and endometrial biopsy
is required.
• Atypical glandular cells - Atypical glandular cells detected by cervical
cytology should be investigated with an endometrial (and
endocervical) biopsy to determine whether an endometrial neoplasm
is the cause.
• Endometrial cells – The presence of endometrial cells on cervical
cytology is reported in the results in women ≥40 years of age. The
appearance of normal endometrial cells on cytology in asymptomatic
premenopausal women is rarely associated with pathology and no
further work-up is required.
CLINICAL MANIFESTATION
• Incidental finding on imaging
• A thickened endometrial lining is sometimes found
incidentally on ultrasound, computed tomography (CT), or
magnetic resonance imaging (MRI) performed for another
indication.
• Incidental finding at hysterectomy
• Endometrial carcinoma or hyperplasia is sometimes
discovered incidentally when hysterectomy is performed for
benign disease.
• Prior to hysterectomy, all women with abnormal uterine
bleeding should have endometrial sampling
WORK UP
WORK UP
• Endometrial sampling
• Office endometrial biopsy,
• Can be performed without anasthesia.
• D&C in some women.
• Cannot tolerate an office biopsy
• Those with heavy bleeding (D&C is both a diagnostic and
therapeutic procedure),
• Hysteroscopy with D&C to ensure that focal lesions are
identified and biopsied.
WHAT ABOUT SCREENING
• Routine screening is not advisable except for
women known with Lynch syndrome
PATTERN OF SPREAD
• Direct extension to adjacent structures.
• The most common
• Invade through myometrium reaching the serosa
• Grow downward and involve the cervix.
• Uncommon ..vagina, parametrium
Bladder and rectum.
• Exfoliated cells may pass through the fallopian tube
and implants on the ..
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Ovaries.
Viscera.
Parietal peritoneum.
Omentum.
• Lymphatic spread
• Pelvic lymph nodes.
• Para-aortic lymph-nodes.
• Hematogenous spread.
• Less common
• Liver.
• Lung.
MANAGEMENT
• Endometrial cancer is surgically staged disease
• Further management depends on the stage
• Basic surgery include
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Total hystrectomy
Bilateral salpengo-oherectomy
Bilateral pelvic lymphadenectomy
Para-aortic lymphadenectomy
Omentectomy and peritoneal washing in type II
PREOPERATIVE WORK UP
• In endometrial biopsy
• Tumor histology type
• Tumor grade
• Risk of lymph node involvement
• G1 3% Pelvic… 2% aortic
• G2 9% pelvic…5% aortic
• G3 18% pelvic… 11% aortic
FIGO STAGE
• Stage I
• Tumor confined to the uterus
• IA.. Less than 50% myometrial invasion
• IB … more than 50% myometrial invasion
• Stage II
• Invading cervical stroma but does not extend beyond the
uterus
FIGO
• Stage III
• Tumor extend beyond the uterus
• IIIA… serosa of the uterus and or adnexa
• IIIB …vagina or parametrial involvement
• IIIc…lymph nodes
• IIIc1 pelvic lymph nodes
• IIIc2 para-aortic lymph nodes
FIGO
• Stage IV
• IVA… bladder or bowel mucosa
• IVB… abdomial metastasis or inguinal lymphnode
WHEN TO GIVE RADIATION
• Types of radiation
• External beam radiotherapy
• Brachytherapy
WHEN TO GIVE CHEMOTHERAPY
• Type II tumor
HORMONAL TREATMENT
PROGNOSIS AND SURVIVAL
Stage
I
II
III
IV
5 – year survival (%)
90 - 95
70 - 80
35 - 50
15 - 20
FOLLOW UP
OTHER TYPES
• Uterine sarcoma
• Endometrial stromal tumors
• Mixed mullerian tumor
THANK YOU
KARIMA SALAMA